 Hi everyone and welcome to the Addiction Recovery Channel. I'm Ed Baker and I'm your host producer. Today we have a treat in store. We're very fortunate indeed to have Dr. Richard Russen with us for the show. Thank you Dr. Russen for being with us. Thanks for inviting me. Yes. Just a little bit about Dr. Russen before we begin. Rick is an emeritus professor in the Department of Psychiatry at Biobehavioral Science at UCLA School of Medicine. He's also a research professor at the University of Vermont. Dr. Russen has conducted an extensive portfolio of research on methamphetamine which we'll be talking about today. Methamphetamine is one of the drugs that is increasingly being used in America and in Vermont and increasingly causing death. Rick has been involved in projects on behavioral and medication treatments for methamphetamine. He's also was a member of the Federal Methamphetamine Advisory Group for Attorney General Janet Reno. During the past decade Dr. Russen has worked with the National Institute of Drug Use, the Substance Use and Mental Health Services Administration, the U.S. State Department, the World Health Organization, and the United Nations Office of Drugs and Crime. He's worked on international substance use research and training projects exporting U.S. technology and addiction science throughout the world. Dr. Russen has published three books, 40 chapters, and other books in over 240 professional papers. Thank you Dr. Russen for taking the time out of what looks to be a brutal schedule to join us today. We appreciate you being here. You're welcome. You know, I'd like to just set the context for the show a little bit by speaking about the history of substance use lethality in America and in Vermont. I remain alarmed by this and I just want to share that alarm a little bit. Historically in 2015 the Drug Enforcement Administration in their National Drug Threat Assessment noted 700 deaths attributable to fentanyl between late 2013 and late 2014. So 700 fentanyl related deaths. As of April 2021 for the 12-month period ending April 2021, there have been 68,000 deaths directly attributable to fentanyl. So from 700 in late 2013 to late 2014 to 68,000 a mere six or seven years later, this to me is incredibly shocking and alarming. Current reports in America cite fentanyl as being the number one cause of death for Americans aged 18 through 45. Rick, let's start with that. Let's start with a discussion of the national trends historically and what exactly is happening. What is happening? Well, the United States has always had these cycles of illicit drug use. Generally, they've cycled between periods of high rates of stimulant use and then followed by high rates of opioid use and then back to stimulant use. We saw that in the 90s and the early 2000s when we had high rates of methamphetamine and cocaine use. But then beginning in the mid first decade of the 2000s, we started to see the onset of the current opioid crisis. Starting with prescription opioids, which certainly here in Vermont, we saw in very high amounts painkillers that were being prescribed and diverted, switching over to heroin that occurred during the like 2013, 14, 15, and then recently fentanyl. Now, when I was doing my work in one of the other phases of my career in California, I was running clinics that provided methadone treatment. I remember one time we had a police report in the community that there was a pharmacy burglary and fentanyl was now out on the street. This was considered a major public health crisis in Los Angeles County that this one source of fentanyl had made it onto the street because the perception of fentanyl at that time and now is that it's so deadly that the idea that it would become mainstreamed as a routine drug on the street was unthinkable. I mean, it was really like, oh my God, fentanyl is on the street. We need to get all this public knowledge out into the community and tell all the patients and now fentanyl is everywhere. It's not only sold as fentanyl in powder form in very small amounts. It's only a tiny amount that it takes to be fatal to produce a fatal overdose. It's actually the cartels in Mexico have determined that this is a product that they want to use as their central product. Now, they stamp it into tablets. Some of it's being sold as oxycontin. Some of it's being sold as Xanax. It's now in most of the stimulants being sold. Most of the cocaine and methamphetamine include fentanyl. It's everywhere. I had a discussion this morning with a group. I talked about it. It's sort of like sugar. It's just sort of mixed in with everything. And that's been a really big change in our landscape of drug misuse and drug addiction in that never before have we had a drug this lethal that's this widely available and has been used everywhere. And that's why these overdose death rates have gone through the roof in the last several years. Incredible. It's incredible to me. If I'm not mistaken, fentanyl is measured in what's called micrograms as opposed to milligrams. Most opioids are measured in units of milligram, which is a thousandth of a gram. A microgram is a millionth of a gram. That's a measure of the lethality of this particular drug. And I mean, that's fine when a pharmaceutical company is doing the production. But when it's an international crime organization mixing a drug with that kind of lethality, you have what we have on the streets today. And your story about California a number of years ago and the alarm in the community I just think that's so appropriate that there should be alarm at that level in the community. And it seems to me today that our culture is becoming desensitized to these incredible numbers. It's almost like it's so painful. We can't look at it. Some statistics have 103,000 deaths in this 12 month period ending April 2021. And there's really no reason to think that the velocity is going to slow down. I know you're a Vermonter and I know you have a love for the state and the people in the state. You've been looking closely at Vermont. So let's take a look at Vermont. The numbers that I have here are in 2010, there were 41 deaths statewide attributable to opioid overdose. In 2021, there were 169 deaths attributable to opioid overdose. Clearly a 400% increase in deaths in Vermont. 2021 is on record to be the worst year ever. As of the end of October, there are 169 deaths. So we've already surpassed 2020 with two months to go. If my calculations are correct, and it doesn't take really much to calculate this fairly accurately, it looks like as of the end of 2021, we will have lost a little over 200 fellow Vermonters to opioid overdose. So this is a 500% increase since 2010, the worst year in Vermont history. Yeah, one of the details in the middle of that that's really so discouraging is that from 2012 or whatever your starting number was, we saw this steep increase in overdose deaths 2012, 2013, 2014, 15, 16, it was almost a 45 degree angle that was going up. But then Vermont's work in producing a hub and spoke treatment system and getting medication assisted treatment widely accepted in the state of Vermont and widely available in the state of Vermont actually leveled off 2017, 2018. We started to see a decrease that we sort of hit the top and it was coming down. And that was clearly the result of all the work that's been done to get medication treatment available to people. And there was really a sense of optimism that maybe we've seen the worst of this crisis, because now we've got so much treatment in the community. And then came fentanyl. And fentanyl has driven those numbers. As you said, I think 2018 or 2019, it was just over 100 people who died of overdose. And now this year, it's going to likely be double that. So it's remarkable what this one drug is done to the to the current environment in Vermont. Yeah, incredible. And the velocity of it is so overwhelming. And you know, Rick, the more I look at it, the more I read about it and study it. And like you, you know, pretty much full-time or double time, you know, this is not a user driven phenomenon. It's not like people who unfortunately have severe opioid use disorder are saying, you know, we want fentanyl. It's more of a supply side driven phenomenon where people have no choice. They're exposed to a contaminated drug supply. They're at the mercy of international criminal organizations. And as a result, they're dying at an unprecedented rate. It is, in fact, in my view, the most vulnerable population at the mercy of ruthless, ruthless predators. And like you say, we have done in Vermont, the response in Vermont has been mighty. You know, you know better than I, how people admire us all through America. When they look at the system in Vermont, they say, wow, Vermont is great. They're really responding with compassion, science to this population. Our response is mighty. But even with the magnitude of our response, it just seems to be overwhelming and out of control. Is that the sense that you have? Yeah. And one point you made about people sort of wandering into the use of fentanyl without knowing what they're getting themselves into. That's true. And that many of them were introduced without knowing they were taking a new drug. They either were buying heroin, and it started to have fentanyl in it, or buying cocaine, and it started to have fentanyl in it. However, if they start taking it over time, then they actually do seek it out because their level of opioid dependence becomes so severe that they need the strong opioid effect of fentanyl to relieve their, or to prevent their withdrawal symptoms. So you actually convert them. I've done some interviews with people who are currently using in Vermont, and they said they won't buy a drug now unless it has fentanyl in it, because they become tolerant and they need the extra potency of fentanyl. So it's actually converted them into regular fentanyl users. I mean, they'll still use other drugs if, for some reason, fentanyl wasn't available, but it is now the drug of choice for many of the individuals. It wasn't at the beginning, but that switched over. So in other words, there's like a conditioning at the Mu receptor, at the opioid receptor that makes the person more dependent on fentanyl than they would be saying on morphine. That's correct. They need fentanyl to relieve withdrawal symptoms. I also understand that the half-life of fentanyl at the Mu receptor, the activity in the brain is shorter acting than morphine. So the person needs to self-administer the drug more frequently. Is that true too? Yeah, that's true. Although there's an interesting paradox in that fentanyl appears to hang around the Mu receptor for quite a while, not in high amounts, but in some amounts, which when people are administered buprenorphine for the first time, we're seeing more difficulty of people to get on buprenorphine because fentanyl will precipitate a withdrawal effect and it'll get symptoms often in their first several doses. It really has caused a challenge for many of the doctors who prescribed buprenorphine because they'll start patients, they'll say to them, look, you need to abstain from opioid use for four to six hours before your first dose. And even if patients do that, they take their dose of buprenorphine and they get some withdrawal symptoms. And that's made induction of people on to buprenorphine more challenging. And it's, we're seeing in some places, I know my colleague who runs a treatment center in California said they're using more methadone now because methadone doesn't have that same problem. And that's a real shame. I mean, methadone is a great treatment, but buprenorphine is able to be used in a much wider array of settings. And it's really a much more makes the treatment more available. So fentanyl is having all sorts of negative effects on our ability on both on the death rate and on our ability to treat people. All of more reason. And I understand that the buprenorphine product containing a nautrexone would cause withdrawal, whereas methadone doesn't contain the nautrexone. That's right. Yeah, there's no antagonist. It's almost like a like a perfect storm of variables that's working against public health in a huge way. You know, let's move now from opioids because you've mentioned it and I've mentioned it. The idea of stimulants and methamphetamine is kind of like the three waves are prescription drugs, heroin, and now fentanyl. And now, lo and behold, in the middle of all this, we have yet a fourth wave, methamphetamine and cocaine. Let's talk a little bit about that because I know you spent a lot of time looking at that record. Yeah, well, as I said, historically, we've had this history of cycles. And obviously, we've just had a massive opioid, what we're still in the middle of a massive opioid epidemic. And predictably, we're starting to see an upswing in in stimulants that Nora Volkov, the director of NIDA has referred to as the fourth wave. And but this is going to be different, because it's not going to be. We had a lot of opioids. Now we're going to just have a lot of stimulants. We're going to have both. We're going to continue to see these mixtures of cocaine, methamphetamine and fentanyl. So we're really at a sea change in kind of how our drug epidemics have unfolded in the United States. But the important point is for individuals here in Vermont, who have maybe historically used cocaine as a recreational drug or used it on occasion, now they're getting a much more potent drug, methamphetamine, the availability of methamphetamine in Vermont for the first time has started to significantly increase. As you know, from the meetings we have monthly with the in Chittenden County, the police are reporting a lot more seizures of methamphetamine. They tend to be the people who see new drug trends first. And that's what they're reporting. Our overdose data are starting to show methamphetamine in a higher proportion of the overdose deaths. And so when I talked with Dan Wolfson at the University of Vermont in the emergency department, he said they're seeing more people coming in with methamphetamine psychosis, as well as methamphetamine related overdose. So this is a trend that we've seen when I was in California and still in California, methamphetamine is by far the biggest illicit drug problem. And Vermont has been kind of protected for whatever reason or from that earlier epidemic, but it's finally made its way here. New Hampshire's seen very high rates of methamphetamine use and overdose related deaths. Vermont is seems to now be sort of the end of the pipeline for this drug. But it actually is now making a major impact in Vermont. I do remember a number of years ago, where there was this threat of methamphetamine traveling across the country to Vermont, we all got geared up for it. That's right. It happened. And it was great that it never happened. But it seems to be happening now, as you say. It looks like the West Coast was protected against fentanyl because of black tar heroin. It looks like fentanyl now is increasingly causing death on the West Coast, while methamphetamine is increasingly causing death on the East Coast. The numbers that I have from the Office of Alcohol and Drug Use Programs is from January to September 2020, there were seven overdose deaths involving stimulants. From January to September 2021, there were 18. So it's almost a tripling of overdose deaths involving stimulants. Now, that's again, almost a 300% increase in one year. I know that, and you've mentioned haven't spoken buprenorphine and the wonderful treatment that is available to people with severe opioid use disorder. I know you've studied methamphetamine and it's kind of a daunting, perplexing disease process. It seems so difficult to actually treat. I think you've made some inroads recently with successful treatment. Do you want to talk a little bit about that? Yeah. Well, and when we're talking about methamphetamine, I mean, in parallel, although the rates of cocaine use have not been going up the same way that they have with methamphetamine, cocaine use is still a significant public health issue, particularly in the African American community and urban centers in the United States. Methamphetamine is starting to encroach on that, but it would be a mistake to think cocaine has gone away and we don't have to worry about that. So both of these psychostimulants, cocaine and methamphetamine, are a class of drugs that have a very different effect than opioids. They affect different parts of the brain than opioids and the medications that we develop for treating people with opioid use disorder are not relevant to the treatment of people with stimulant use disorder. I started doing work in this area. The first paper I published was in 1981, where we were looking at a medication for the treatment of people with methamphetamine and this was in Southern California and it didn't work. It didn't work any better than placebo. I then spent about 20 years of my career running medication trials for cocaine and methamphetamine medications. We tried all kinds of things. We tried antidepressants. We tried anti-seizure medicines. We tried some antivirals that there was a reason to think might work. Nothing has been successful. There's a couple of things now that look a little bit promising, but they're nowhere near the sort of the robust effect of buprenorphine and methadone for opioid use disorder. So we're still really struggling to find the right molecules to produce a medicine to help us with treating people with stimulant use disorder. Now, that's a challenge, but in 1991 here in Vermont, Steve Higgins at the University of Vermont published the first paper in treating people with cocaine use disorder using a technique called contingency management. Higgins, it was a breakthrough paper. I remember in California when I was doing all kinds of behavioral treatment for people with cocaine use disorder, and I saw this paper from Higgins and I thought there's got to be something wrong with this. These rates of success are ridiculous. I know how tough it is to treat people with cocaine and methamphetamine, and he's getting this very high rate of success. Steve and his colleagues at UBM published and published and published and published all the same outcomes that all very robust positive treatment. I should tell you that about two years ago I did some interviews in Burlington with a bunch of people who are current users of drugs, and several of them said, and there were some a bunch of people who were now sober from, and they had been users of drugs, and there were quite a large number who had gotten sober in Steve Higgins' contingency management trials, and were still in recovery. This is a technique that involves the use of incentives for rewarding patients for reducing or stopping their drug use. You have a schedule, people come in, they give urine samples, if they give a negative urine sample for stimulants, they can earn a $10 gift card or something like that. This technique, there's all sorts of variations on how much and how long and all of that, but there have now been in the last five years seven meta-analyses of the literature. These are like where these researchers take all the studies in an area, pull them all together, and draw out the common results, and when that's been done for the treatment of people with stimulant use disorder, both cocaine and methamphetamine, contingency management has by far the most robust treatment effect. Now there's been some reasons why it hasn't been used. It hasn't made its way into the real-world treatment system yet. It stayed in the laboratory. Higgins did his work and his colleagues, or I did some studies, a number of other people did. We all found the same thing. This, wow, this really works remarkably well. But to get this paradigm shift where you're using incentives as a treatment, that takes a big change. It takes the government to change what you can use your funding for because it's an expenditure and you have to get approvals through Medicaid and all that, and that has not been forthcoming. It's been stalled for about 15 years at this point. There's been a breakthrough, though, in the state of California right now. The state has decided to roll out a $58 million pilot project to provide treatment for people with cocaine and methamphetamine use disorder using contingency management. That's being viewed not only here in the U.S., my colleagues in the World Health Organization and the United Nations are monitoring it very closely because around the world, large parts of the world have big problems with methamphetamine and cocaine use disorder, and we literally have no other treatment that has anywhere close to this kind of an effect. And it's great that it's now being used. We had a meeting this morning with the new head of the National Office of National Drug Control Policy, and it's a priority of the Biden administration to make contingency management an available treatment to provide a viable, effective treatment for people with stimulant use disorder. Well, thank you. Thank you so much for your continued focus, you and your colleagues, and I'll tell you, it's great to hear the enthusiasm and the joy in your voice that we need. We need kind of hope about moving forward, and this sounds like a very hopeful intervention. I read a little bit about it, and I also saw that along, that there's also like a component of an important component of exercise, and then what was called, I think, like a positive involvement in an activity. Can you speak to that? There was a few different components. Well, that's those are those are additional interventions that are sometimes used together with contingency management. Okay. Contingency management itself is purely the incentive, the incentive. And there's a little bit of a story to it. It's, you know, if you if you came into treatment and we had a contingency management program and you explained it to you and said, if you can give a drug, a stimulant negative urine, you can earn a $10 gift card. If you can give three negatives in a row, you'll earn a $15 gift card. If you are if you give another three in a row, the increase goes to 1750 per urine. So there's an escalating amount which is intended to help people develop longer periods of abstinence. So you're reinforced for consecutive negative urines. And that that is an important part of contingency management. But while people are on contingency management, their their drug use is reduced. That's great. But they often need assistance in learning. Well, what do I do now? Yeah, yeah, if I've, I'm no longer doing this behavior that took up 80% of my life, getting the money, buying the drugs, using the drugs, recovering from the drugs, getting more money. I mean, all of that becomes all encompassing to the individual uses drugs. So now what do I do with all this time? And so some of the available therapies, things like the community reinforcement approach, which by the way, was first applied to stimulant use disorder by Steve Higgins and his team at the University of Vermont. Cognitive behavioral therapy is used. Our work is involved. When I was at UCLA, we did some work on exercise, and we got some very positive benefits to both people's general health, to their recovery, to their brain recovery. And so we think that in addition to using contingency management, there are other things that are helpful to use with it. Well, I can't tell you, I'm excited by that. And I look forward to further research on that for sure, Rick. And again, it's hopeful, and we need that. Just one point I want to make about that. If you think about what we've done for treatment, for people with addiction over the years, it started out with talk therapy of a variety of kind, whether it was Synanon doing the game, or whether it was 12-step recovery activity, or whether it was cognitive behavioral therapy or motivational. It's all involved talk therapy. The other brand of the other sort of major theme of treatment has involved medication. First, well, we did some work with an abuse back in the 50s and 60s, but methadone came along in the 60s, naltrexone came along in the 70s, buprenorphine came along early 2000s. And so we've had these two tracks of treatment, talk therapy and medication treatment. One of the challenges with contingency management is that it's neither of those. It involves the application of these contingencies, of giving incentives in a systematic way. And I think one of the challenges we have is people going, well, hold it, that's treatment and in fact, it is treatment and it's by far the most robust treatment. And the enthusiasm you hear in my voice is very similar to the enthusiasm I had when I came back to Vermont 2015 and I went out and evaluated the hub and spoke system. It's like, wow, this is great. There's a lot of people benefiting from this who would be using heroin and now are working and holding jobs and having families. I've seen the same thing happen with contingency management with people with stimulant use disorder, but it hasn't been widely used. That seems to be changing and so I'm hopeful about that. That is great, again, and that's great to hear. So let's stick with this theme, like the treatment theme. And hopefully this will take effect in Vermont, contingency management. But let's go back to opioids now and take a look at, there's been a mighty response in Vermont. I just jotted down some of the responses that come to mind immediately. So we have medications for opioid use disorder. We have the magnificent hub and spoke program widely, wide net over Vermont that's very, very successful. I think there's no waiting list. The waiting list is zero. We have the recent legislation that decriminalized the possession of small amounts of non-prescribed buprenorphine. Very, very progressive move in Vermont. We're recognizing that people who may be possessing buprenorphine may be possessing it because they're trying to get off heroin and trying to enable themselves to stop using fentanyl. We have various harm reduction techniques. We have fentanyl test strips. We have a wide spread distribution of naloxone to reverse overdoses. We have safe syringe programs. We have outreach. There's a lot, there's a mighty, mighty response. But in spite of our response, and I like you to elaborate on that a little bit, what you have, what you think of our response. But in spite of that response, Rick, we have the numbers that you and I have both cited earlier in the show. So I want to move, I want you to elaborate on that a little bit, but then I want to move into this next idea of overdose prevention sites and what is keeping us from implementing this next science-based, unequivocal best practice when it comes to saving the lives of people with severe opioid use disorder. So speak to that for a minute, please. Well, I think the fentanyl was a game changer. My fentanyl was the lethality of this drug and this rate of overdose death increase that's gone through the roof has actually gotten policymakers to step back and go, hold it. We've always thought about our efforts in addiction treatment as being about the promotion of recovery, getting people sober, helping people get drugs out of their lives or getting abstinence so they can have a drug-free life and develop the benefits of being sober. And that's really been our focus and almost our exclusive considerations. What do we need to do to help people get sober? And that's important and that's been a that's paid dividends and has made some help. Many people get their life safe. However, with fentanyl, we have to take a step back and go, well, hold it. Is getting people sober our first priority or is keeping people from dying our first priority? Because dead people don't recover. And so you can have the best programs in the world to help people get sober. But a lot of them are never going to make it to those programs. As people get ready to go into treatment, it takes people varying lengths of time before they're willing to go into treatment. And with fentanyl on the street, those varying lengths of time are lethal. And so we've had to step back and say, okay, what do we need to do now? Let's refocus our efforts on how do we keep people from dying. And we know that methadone and buprenorphine have the benefit of keeping people from dying and other forms of treatment. But there's a lot of people outside that system who and it's not unique to Vermont or to this particular disorder. People with all kinds of psychiatric and medical disorders don't immediately jump into treatment. They often have to go through a process of, do I really need to do this? Maybe if I do this, I can manage it myself. And while all that's going on now with a drug like fentanyl, it just takes a tiny error in dosing from getting high to getting dead. And so this issue of what kinds of things can we do for people that will reduce their risk of death before they actually or for some people who may never get into treatment. But still, that shouldn't be a death sentence. There should be some alternative that we can provide that reduces the risk of death. Certainly syringe exchange helps and naloxone helps. All of those things are great. But there's still a hole in the system where people who have not made their way into treatment require some kind of alternative to help them if they're going to continue to use, but to help them not die. And that's where these overdose prevention efforts have come in, which, as you know better than I, are being used in Rhode Island and in New York. And of course, outside the United States have been used for quite a few years in Vancouver and in Europe they're used and they have data to show that they work. And we're now starting to see them develop here in the United States. Yeah. And thank you. And as you mentioned, I was brought up in my recovery to be abstinence centering. That was the belief system that was handed over to me. It saved my life. And I believe deeply in it. And in the face of the velocity of death in America, I've had to expand my thinking. First I had to move into the acceptance of harm reduction. Had to get rid of all my prejudices about enabling and oh coddling and not hitting bottom and all this. We're just perpetuating this drug use. Had to get rid of all that. And then I had to get rid of this idea of actually providing a place where people could safely inject drugs. It's very, very far from abstinence. But as a professional, and it even goes deeper than being a professional, I think there's an ethical demand to educate ourselves about this, to look at the science. And as professionals, if we do that, we have to change our view. We have to change our view to match the science. But even deeper than that Rick, I'm morally compelled to speak out on this continuously to try to raise consciousness about this. That to do nothing as a state is to allow further death. And this is completely unacceptable. I'd like to, I'd like you to maybe just, can you talk a little bit about the evolution of your thinking? I mean, did you always in support of overdose prevention sites or has it been a genesis for you? No, I mean, my training in my, the work I did was always working with treatments that would either promote abstinence or promote a dramatic reduction in use with medications like uprenorphine and methadone. And I gradually became familiar with the harm reduction rationale and the idea that abstinence shouldn't be our only metric or only successful outcome. But if you can reduce people getting HIV, if you can reduce people getting hepatitis, those are good things to be able to do too, even if those people have not developed total abstinence from drugs. If it's not only good for them, it's good for society because having them get HIV and hepatitis is a very big healthcare cost. And so it's, so I started to become much more sympathetic to the idea of harm reduction. And Ed, you're saying it took you a while to come around. I sent you a paper email from the director of the National Institute on Drug Abuse. That's her first paper last week where she talks about harm reduction is something we should be thinking about. And that's a big sea change for the National Institute on Drug Abuse because their history had always been sort of treatment, abstinence, reduction, harm reduction we're not so sure about. But in her paper was the last paragraph was on overdose prevention sites. And for me, even though I got along and recognized the value of syringe exchange and naloxone distribution and all of that, opioid overdose prevention sites where people go and actually use the drugs under supervised conditions, it seemed to me, okay, maybe in the big cities, maybe in Philadelphia and New York City, there might be enough people to support or that would need that. But Burlington, I don't know if Burlington really needs to have us because those services are not inexpensive to set up. They have to be supervised. Do we really, maybe we can just get everybody into treatment. That was kind of how I was thinking five years ago. Fennel comes along, the overdose death rate goes through the roof, even though we've got buprenorphine prescribers throughout the state and methadone clinics and people can get any treatment they want, like you said, no waiting list, but we still have all these people dying. Where's the hole? The hole is the fact that there are some people who are going to continue to use and we need to provide them an alternative. And the data says these overdose prevention sites can do exactly that. If people go to overdose prevention sites, their overdose death risk is dramatically reduced. And that's important. That's an important development to recognize that and to set up something for those folks. Yeah. And as a scientist, we have to, as professionals, we have to open our minds to that science, which sometimes can be difficult. Very well said. Yeah. Well, it was a tough one. I mean, when Keith Del Pozzo was still around and we would talk about that, he would ask me and I would go, you know, if Burlington was a million people, I would be all for it. But with the size of the city of Burlington, I just don't know, but there's no question now. I mean, if you look at the data that we see every month at the mayor's meeting that we go to Comstat, clearly the overdose deaths are going up. Every month we go in, they're showing an increase over the month last year and double over the year before that. So it's certainly the case has been made by the data that we need something for these folks. Absolutely. You know, the Department of Health and Human Services requested a report on overdose prevention sites. And I want to read just a couple of sentences from the conclusion on the report. So the report was done by the National Institute of Health and the National Institute of Drug Abuse. This is November 2021. This is in their conclusions and it kind of summarizes, it reflects exactly what you just said. This is a quote. This is from the conclusions. The preponderance of the evidence suggests these sites are able to provide sterile equipment, overdose reversal, linkage to medical care for addiction and the virtual abstinence in the virtual absence of significant direct risks like increases in drug use, drug sales or crime. How much clearer can you get? They go on to say overdose prevention centers may represent a novel way of addressing some of the many challenges presented by the overdose crisis and they could contribute to reduced morbidity and mortality and improved public health. Then they go on to cite that none other than the American Medical Association has also endorsed overdose prevention sites. So I mean, I don't, when I hear arguments, I hear arguments all the time because I'm sort of in the middle of all this and I hear arguments from very well informed high level people with power and I don't understand how they can still offer what I consider specious arguments against overdose prevention sites. It's just boggling my mind how there seems to be this wall of resistance in spite of clear unequivocal science, not just any old science, but the National Institute of Health, NIDA, Nora Volkov, people speaking out, it just is boggling my mind and it just makes the sense of urgency even, you know, stronger as we move forward. You know, when you think about the legislative year and it being over and having to wait to 2023, it just seems like now really is the time for people to speak out and rally for fellow Vermonters with severe substance use disorder, you know. I do think, Ed, that part of what our challenge is, I mean these numbers of death, this rate of death increase is really stunning, like shocking, but it's occurred during the two years of the pandemic. I mean the overlay of fentanyl deaths and the pandemic have been almost right on top of each other and I think there's been, I mean the Department of Health in the state of Vermont has been swamped with dealing with the COVID crisis and I mean, poor Dr. Levine, I hear him on the radio every day, I mean it's like he's his tenure as director of health in Vermont has just been, I don't know how he's done it, but I mean I think if it wasn't for all the attention, necessary attention given to the COVID crisis, these numbers of drug overdose deaths would probably be getting far more attention because we've never seen anything like it. And I think that once you get people to focus on that and you link, you say, look, we've got a responsibility to try to keep people from dying, these things are all good, but this could also be a way of dramatically reducing within some groups death rates. I think it's been hard to get through the noise of the pandemic with these arguments. I agree with you, but that's become my full time intent for 2022. And I have a lot of people that are in support here, I'll just read you some of the people that signed off on a letter that we sent to the state legislature. So I'll tell you where their organization is, the American Civil Liberties Union, city council of Brownington, the mayor, Mayor Weinberger, physicians, families, and friends education fund. You're familiar with Vamhar, Vermont Alliance for Mental Health and Addiction Recovery, Chittenden Towney State's Attorney, Sarah George, United Way of Northwest Vermont, Vermont Addiction Professionals Association, these decisions are the association of people on the front line dealing with people with substance use disorder, the Vermont Recovery Advocacy Project, Vermont Recovery Network, Vermont is for criminal justice spectrum, you know, there's a like a groundswell of support. And you know, Rick, I mean, I can't even, you know, when you mentioned people in the health department, I mean, I've been at meetings and they're working 60 hours a week, you know, it's just incredible what they're doing. They deserve all the credit in the world. And so does Vermont for being a mighty little state courageous. But it's this last kind of step, you know, this next step of overdose prevention sites that we have to take. And you know, if you look to Rhode Island, the legislature passed in a magnificent, beautiful legislation, two centers are going to open in March, support statewide from the top down and straight across, no doubt about it, they're going to do it. New York City on point, two overdose prevention sites, both in Manhattan, one in East Harlem, one in Washington Heights. Now, New York, the legislature didn't do it. But the entire state government and the commissioner of health are behind it 100%. The governor, the mayor, the district attorneys, but for Staten Island, the commissioner of health, the only person who hasn't spoken out in New York is the US Attorney General, where there's like silence. But somehow they felt that that silence was enough to invest a lot of money in setting up two sites. So when I look at that, when I look at that, I tell myself that Vermont has to be number three. You know, Rhode Island and New York can be number one and number two, but Vermont has to be number three. And in my way of saying things, in my own naive little capsule that I'm in, I'm not a big politician, I don't deal with all this kind of stuff. But from my little capsule, we have to do this. And we have to do this this year. This has to happen. It has to happen in Vermont. And you know, with people like you, you know, noted, you know, scientists speaking out about this, I had John Kelly on, Recovery Research Institute, he was supportive. I had your colleague Dan Chikaroni on, he was supportive. You know, I've had some some noted people on the show speaking out with the same with the same voice, with one voice. Hopefully, you know, we'll we'll make a little bit of a difference. And getting this to happen, you know, immediately. I certainly know. I mean, fentanyl has been a game changer. It's so lethal. And the people who are addicted to it, they're at very high risk for death. And for some of them, a facility like this would would will be the difference between them living and dying. And it and it's that simple. And the question is, how do we where's where are we going to put it? And how are we going to fund it? And let's get going with it, because I think we're at that point now, we did a heat map. The city, the mayor's committee did a heat map, we had a heat map done. And if you look at it, it's like looking down on the Burlington, Greater Burlington, Chittenden County, if you look, it's looking down at there's like an intense concentration of overdose around Burlington and the surrounding areas. And if you overlay public transportation on top of that heat map map, you see all the public transportation lines heading into Burlington. So it looks like it would be Burlington. I have it on very good, a reliable source that that the number of deaths in Chittenden County for 2021 is 44 with nine pending. So somewhere between 44 and 53 overdose deaths in one county for 2021. So I mean, how much more urgent could it possibly get? Yeah. Yeah, no, I agree. And I think that it's, I don't think we're at a point now of, should we do this? It's clear that we should do it. It's how do we do it? And exactly what steps can we get taken in order to make this happen? And I think that's the next challenge is figuring out the steps, because I know you had the call with the Rhode Island folks, they're more than willing to help and provide advice and exactly how you do it and how you staff it and what hours you need and all of that. So there is some experience that could be very helpful to Vermont in setting up a site. It's just a matter now of like, okay, how do we do it? Yeah. Yeah. All right. Well, you know, I want to thank you for your support. I want to thank you for making time once again to come on the show. You're just the greatest of guests. And I'll look forward maybe over the course of the coming year, maybe to have you on again, maybe we'll talk a little bit more about contingency management and where that's going with stimulant use disorder. I'd like to see Vermont get that going too, because I think that other states are doing it. And I think it's Vermont's been a leader. And I think Vermont, because it was invented in Vermont, Vermont should be implementing it. I agree with you, Rick. I agree with you. So thank you. And thank you to my viewing audience for joining us today. And we'll see you next month. And you know, stay warm. Thank you. That's right. Thank you, Ed.